Knowledge Base Article

Medicare has recently added yet another review contractor to audit your claims – the Supplemental Medicare Review Contractor (SMRC). So why does CMS need so many contractors to fight improper payments and ensure compliance? And what are the differences between the different contractors? I am not sure the answers are really clear, but here is some information from a recent transmittal about the various contractors and their functions.

CMS Transmittal 508 updates the Medicare Program Integrity Manual to include information about the Supplemental Medicare Review Contractor. According to the manual update, SMRCs, along with CERT contractors, Medicare Administrative Contractors (MACs), and Recovery Auditors (RAs) are contracted by CMS to fight improper payments and promote provider compliance in the Medicare fee-for-service program.

CERT Contractors

The CERT program establishes error rates and estimates of improper payments (implemented as part of the Improper Payments Elimination and Recovery Improvement Act).

Medicare Administrative Contractors (MACs)

MACs prevent improper payments through initiatives to help providers comply with Medicare’s coverage, coding and billing rules. This is accomplished through provider education; pre-and post-payment claim review; and local coverage determinations (LCDs), articles, and coding instructions. The MACs use error rates and vulnerabilities identified through the CERT and RA programs to target their efforts.

Recovery Auditors

Because of the large volume of claims that Medicare processes and the difficultly with catching all improper payments, the RAs provide additional review to detect and correct improper payments to help protect the Medicare Trust Funds.

Supplemental MR Contractor (SMRC)

The SMRCs are a centralized medical review (MR) resource that can perform large volume MR nationally. They perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs. The focus of SMRC reviews may include but are not limited to issues identified by CMS internal data analysis, the CERT program, professional organizations and other Federal agencies, such as the OIG/GAO and comparative billing reports. Their primary duties include:

• Serving as a readily available source of medical information to provide guidance in questionable situations, including questionable claim review situations
• Providing the clinical expertise and judgment to develop LCDs and internal MR guidelines
• Keeping abreast of medical practice and technology changes that may result in improper billing or program abuse
• Providing clinical expertise and judgment to effectively focus MR on areas of potential fraud and abuse

Are the differences between the contractors clear as mud? Yes, I thought so. But even so, you need to know who the Medicare contractors for your region are. You can find that information by using the Review Contractor Directory.